Pelvic Organ Prolapse Flashcards
Define prolapse
descent of the uterus and/or vaginal walls beyond normal anatomical confines
Define the following: Urethrocoele, cystocoele, uterine prolapse, enterocoele, rectocoele, vault prolapse
Urethrocoele = prolapse of the lower anterior vaginal wall, involving the urethra only
Cystocoele = prolapse of the upper anterior vaginal wall, involving the bladder and often the urethra (cystourethrocoele) (C)
Apical/uterine prolapse = prolapse of the uterus, cervix and upper vagina. If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can itself prolapse (b)
Enterocoele = prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel (e)
Rectocoele = prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum (d)
Vault prolapse = prolapse of vaginal vault after hysterectomy
What are the causes of pelvic organ prolapse
Due to weakness in the supporting structures
Vaginal delivery and pregnancy: large baby, instrumental delivery, high parity
Congenital: Ehlers-Danlos syndrome
Menopause
Chronic predisposing factors: obesity, chronic cough, constipation, heavy lifting, pelvic mass
Iatrogenic: pelvic surgery e.g. hysterectomy that incises the uterosacral ligaments
What muscles make up the levator ani
Puborectalis
Pubococcygeus
Iliococcygeus
What are the symptoms of pelvic organ prolapse
Dragging or heaviness sensation (worse at the end of the day and on standing)
Sensation of a lump
Stress incontinence
May need to manually reduce the prolapse with finger to pass urine or stool
Cystourethrocoele: urinary frequency | incomplete bladder emptying | incontinence | recurrent UTIs
Rectocoele: difficulty defecating | back pain | sensation of incomplete emptying
Severe: interferes with intercourse | ulceration | bleeding | discharge
What are the differentials for a pelvic organ prolapse
Polyp
Vaginal cyst
What are the signs of pelvic organ prolapse on examination
Abdo: ? pelvic mass
Pelvic:
- ?visible prolapse
- Ask patient to stand and cough/strain
- Speculum: ask patient to bear down, observe for prolapse
- Rectocoele/enterocoele suspected: put a finger in the rectum: the finger will bulge into a rectocoele but not into a enterocoele
What investigations should be done for pelvic organ prolapse
Clinical diagnosis
Assess and record the presence and degree of prolapse using the POP-Q (Pelvic Organ Prolapse Quantification) system
Pelvic mass: CA-125
± urodynamic testing if incontinence present
How are pelvic organ prolapses graded
Baden-Walker
0: No descent of the pelvic organs during straining
1: Leading surface of prolapse does not descend below 1cm above the hymenal ring
2: Leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring
3: Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion
4: Vaginal completely everted (complete procidentia)
What is the management for asymptomatic pelvic organ prolapse
Reassure and advise to avoid treatment
Advise to seek advice if they become symptomatic
What is the management for symptomatic pelvic organ prolapse
Conservative: lose weight, treat any chest problems, stop smoking, avoid heavy lifting
1. Exercises for the pelvic wall
2. Pessary - supports the bulge from coming down
3. Surgery - under GA or waist down. Stitch with cut in vagina and bladder.
Describe the exercises recommended for pelvic organ prolapse
The prolapse will not be reduced, but symptoms may improve
Kegel exercises
Squeezy app
Describe pessary use for pelvic organ prolapse
For women unwilling or unfit for surgery
These are plastic devices that are placed in the vagina to stay behind the symphysis pubis and in front of the sacrum
- Ring pessary (allows for menstruation)
- Shelf pessary (more efficient for severe prolapse)
Changed every 6-9 months
Postmenopausal women: risk of vaginal ulceration
→ topical oestrogen replacement or HRT
Describe the surgery for pelvic organ prolapse
4-6 week recovery. 30% chance of recurrence
1/3 worse, 1/3 the same, 1/3 gets better
Do a urodynamics before surgery
Vaginoplasty: Pelvic floor repair where the vaginal walls are tightened
Anterior colporrhaphy: the vaginal wall is repaired following a cystocele.
Posterior colporrhaphy: rectocoele
Hysterectomy
Hysteropexy (uterus and cervix are attached to the sacrum)
Sacrocolpopexy or sacrospinous fixation (attaching the vagina to a bone or ligament directly (spinous) or via mesh (colpopexy)
What is the prognosis for pelvic organ prolapse
Risk of pelvic organ prolapse recurring is uncommon AFTER surgical reconstruction
The more severe the prolapse, the more likely for recurrence
Almost 30% of women undergoing a pelvic organ prolapse procedure will have another procedure
